Citation Nr: 20028847 Decision Date: 04/24/20 Archive Date: 04/24/20 DOCKET NO. 17-50 365A DATE: April 24, 2020 ORDER Entitlement to an initial disability rating in excess of 10 percent for femoral acetabular impingement syndrome with osteoarthritis and degenerative arthritis of the right hip with residuals status post arthroscopic surgery of the right hip is denied. Entitlement to an initial compensable disability rating for right hip limitation of flexion is denied. Entitlement to an initial disability rating in excess of 10 percent, prior to January 15, 2018, for femoral acetabular impingement syndrome with osteoarthritis and degenerative arthritis of the left hip with residuals status post arthroscopic surgery of the left hip is denied. Entitlement to an initial compensable disability rating, prior to January 15, 2018, for left hip limitation of flexion is denied. Entitlement to a disability rating in excess of 30 percent from March 1, 2019 forward, for left hip total arthroplasty is denied. FINDINGS OF FACT 1. At all times relevant to this appeal, the Veteran’s femoral acetabular impingement syndrome with osteoarthritis and degenerative arthritis of the right hip with residuals status post arthroscopic surgery of the right hip was manifest by limitation of adduction manifested as cannot cross legs. 2. At all times relevant to this appeal, the Veteran’s right hip limitation of flexion was manifest by limitation of no less than 45 degrees. 3. At all times relevant to this appeal, the Veteran’s femoral acetabular impingement syndrome with osteoarthritis and degenerative arthritis of the left hip with residuals status post arthroscopic surgery of the left hip was manifest by limitation of adduction manifested as cannot cross legs. 4. At all times relevant to this appeal, the Veteran’s left hip limitation of flexion was manifest by limitation of no less than 45 degrees. 5. At all times relevant to this appeal, the minimum rating of 30 percent, and no more, is warranted for the Veteran’s left hip total arthroplasty. CONCLUSIONS OF LAW 1. The criteria for Entitlement to an initial disability rating in excess of 10 percent for femoral acetabular impingement syndrome with osteoarthritis and degenerative arthritis of the right hip with residuals status post arthroscopic surgery of the right hip have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5003-5253. 2. The criteria for Entitlement to an initial compensable disability rating for right limitation of flexion have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5003-5252. 3. The criteria for Entitlement to an initial disability rating in excess of 10 percent, prior to January 15, 2018, for femoral acetabular impingement syndrome with osteoarthritis and degenerative arthritis of the eft hip with residuals status post arthroscopic surgery of the left hip have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5003-5253. 4. The criteria for Entitlement to an initial compensable disability rating, prior to January 15, 2018, for left hip limitation of flexion have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5003-5252. 5. The criteria for Entitlement to a disability rating in excess of 30 percent from March 1, 2019 forward, for left hip total arthroplasty have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5054. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Navy from August 1989 to June 2015. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a November 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Winston Salem, North Carolina. These matters were last before the Board in June 2019, at which time they were remanded for further development. The Board finds there has been substantial compliance with the remand directives. Stegall v. West, 11 Vet. App. 268 (1998). 1. Entitlement to an initial disability rating in excess of 10 percent for femoral acetabular impingement syndrome with osteoarthritis and degenerative arthritis of the right hip with residuals status post arthroscopic surgery of the right hip and to an initial compensable disability rating for right hip limitation of flexion. The Veteran contends that he is entitled to an initial disability rating in excess of 10 percent for femoral acetabular impingement syndrome with osteoarthritis and degenerative arthritis of the right hip with residuals status post arthroscopic surgery of the right hip. He further contends that he is entitled to an initial compensable disability rating for right hip limitation of flexion. Service connection for femoral acetabular impingement syndrome with osteoarthritis and degenerative arthritis of the right hip with residuals status post arthroscopic surgery of the right hip was granted in a November 2015 rating decision at 10 percent from July 1, 2015, and is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5003-5253, for impairment of the thigh. Hyphenated Diagnostic Codes are used when a rating under one Diagnostic Code requires use of an additional Diagnostic Code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. Under Diagnostic Code 5253, a 10 percent rating is warranted for limitation of rotation of affected leg, cannot toe out more than 15 degrees. A 10 percent rating is also warranted for limitation of adduction, cannot cross legs. A maximum 20 percent rating is warranted for limitation of abduction, motion lost beyond 10 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5253. Service connection for right hip limitation of flexion was granted in a November 2015 rating decision as noncompensable from July 1, 2015, and is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5003-5252, for limitation of flexion of the thigh. Under Diagnostic Code 5252, a 10 percent rating is warranted for flexion limited to 45 degrees. A 20 percent rating is warranted for flexion limited to 30 degrees. A 30 percent rating is warranted for flexion limited to 20 degrees. A maximum 40 percent rating is warranted for flexion limited to 10 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5252. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See, DeLuca v. Brown, 8 Vet. App. 202 (1995); see also, Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See, Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a criteria.”). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See, Burton v. Shinseki, 25 Vet. App. 1 (2011). In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing “for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint.” In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. The Veteran was afforded a VA hip and thigh conditions examination in June 2015. The Veteran reported chronic bilateral hip pain and a history of bilateral arthroscopic hip surgery in 2012. The Veteran further reported current pain, an inability to run or swim, limitations with walking, the use of stairs and prolonged standing or sitting. He also reported the pain interferes with his sleep. He then reported flare-ups of bilateral hip pain that are associated with limited range of motion and limited mobility. Upon examination, initial range of motion (ROM) of the right hip was measured as follows: 100 degrees flexion with pain; 30 degrees extension; 45 degrees abduction; 25 degrees adduction; 50 degrees external rotation with pain; and 40 degrees internal rotation with pain. The pain, but not the ROM, was noted as causing a functional loss. Pain on weight bearing and localized tenderness or pain on palpation were not noted, but crepitus was. The pain, but not the ROM, was noted as causing a functional loss. Pain on weight bearing and localized tenderness or pain on palpation were not noted, but crepitus was. No additional loss of function or range of motion were noted after repetitive use. Regarding repetitive use over time and flare-ups, the examiner stated that he would have to speculate and, as such, could not provide an opinion. Strength testing was normal and ankylosis was not noted. Occasional use of a cane was noted. An October 30, 2015 private treatment record from Orthopaedic Associates of West Florida notes the Veteran presented with bilateral hip pain that had its onset in 2010. The pain was described as mild but throbbing, constant and worsening. It was noted that the Veteran was active and wants to remain that way. It was noted that the Veteran walks with a painful, stiff gait and that he "also has a Trendelenberg gait with a slight abductor lurch." X-rays were noted as revealing right hip unilateral primary osteoarthritis and right thigh osteoarthritis. Severe degenerative joint disease was noted. The Veteran was then described as a candidate for left and right total hip arthroplasty, noting that “both hips are symptomatic and have significant radiographic arthritis”. A May 3, 2016 private treatment record from Naval Special Warfare Command notes the Veteran wakes 3 to 4 times nightly and gets up to walk and find a position of comfort due to his hips. It was then noted that his hip pain has caused him to fall when getting out of bed, and has pain that radiates from his hips to his glutes and posterior thighs to the back of his knees. Active range of motion was measured as follows: 110 degrees flexion; 20 degrees extension with pain at end ranges; 20 degrees seated external rotation; 20 degrees internal rotation with pain; 20 degrees abduction; and 10 degrees adduction. Passive range of motion was measured as follows: 120 degrees flexion with pain; 20 degrees extension; 30 degrees supine external and internal rotation; and 20 degrees abduction and adduction. Manual muscle testing was noted as 4 of 5 with pain. Fifty percent squat with increased pain was noted. Bilateral "hip replacement procedures in the coming months" were noted. In his October 2017 appeal to the Board, the Veteran stated that "both of [his] hips are unable to bear any body weight without extreme pain" and that he cannot walk without having extreme pain in both of his hips. He further stated that he "cannot sleep for more than a few hours without waking up from extreme pain" and that the measurements in the rating decision "are based off [his] pain threshold and the flexion and extension limits are all how far [he] can go until it is unbearable." He asserted that he can cross his legs only with "extreme pain" and that he cannot hold the position for long. An October 24, 2017 private treatment record from Orthopaedic Associates of West Florida notes the Veteran reported intermittent hip pain, and that he is unable to run without hip pain. Restricted ROM was noted. A January 8, 2018 private treatment record from Orthopaedic Associates of West Florida notes the Veteran had severe bilateral hip osteoarthritis with intermittent pain. A March 20, 2018 private treatment record from Orthopaedic Associates of West Florida notes the Veteran was "back in the gym increasing his activities" and that his strength was improving. It was then noted that he also "has advanced right hip [osteoarthritis] but [is] currently asymptomatic." The Veteran was afforded a VA hip and thigh conditions examination in December 2019. The Veteran reported constant right hip pain that varies according to his level of activity and that his doctor has recommended a right hip replacement, but stated that he was not ready. No flare-ups were noted, but he did report that he can sit for 30 minutes before his hip hurts, more right than the left (groin area). He further reported that he can stand for 45 minutes then has to shift around and sit. He then reported that he can walk 100 yards before his right hip pain starts to increase and he has to sit. He then stated that he can walk up or down a flight of stairs but does not do more than that as he has to take one step at a time. Upon examination, initial ROM of the right hip was measured as follows: 90 degrees flexion; 30 degrees extension; 20 degrees abduction; 20 degrees adduction; 30 degrees external rotation; and 25 degrees internal rotation. It was noted that adduction is limited such that the Veteran cannot cross his legs and that his ROM contributes to a functional loss due to difficulty squatting down and pain noted upon examination (all measurements but external rotation). Pain on weight bearing and crepitus were noted. No additional loss of function or ROM was noted after repetitive use testing. No use of assistive devices was noted. It was noted that pain on passive ROM could not be performed. The Board finds that the preponderance of the evidence is against a rating in excess of 10 percent for femoral acetabular impingement syndrome with osteoarthritis and degenerative arthritis of the right hip with residuals status post arthroscopic surgery of the right hip. The Board acknowledges the Veteran’s lay reports of symptoms and that there was functional loss due to pain. However, even considering the Veteran’s lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the Veteran’s statements would not result in symptoms more nearly approximating flexion limited to 30 degrees. Furthermore, the Board finds that the preponderance of the evidence is against an initial compensable rating for right hip limitation of flexion. The Board acknowledges the Veteran’s lay reports of symptoms and that there was functional loss due to pain. However, even considering the Veteran’s lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the Veteran’s statements that would not result in symptoms more nearly approximating flexion limited to 30 degrees. The Board has also considered the other Diagnostic Codes pertaining to the hip and thigh. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See, Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); see also, Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that 38 C.F.R. § 4.14 prohibits paying compensation twice for the same symptoms or functional impairment). However, aside from the already separate ratings under 5003-5252 and 5003-5353, the rule against pyramiding prohibits any additional ratings under DC 5250, DC 5251, DC 5254, and DC 5255. See 38 C.F.R. § 4.14. As such, no additional ratings may be granted. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran’s appeal for a rating in excess of 10 percent for femoral acetabular impingement syndrome with osteoarthritis and degenerative arthritis of the right hip with residuals status post arthroscopic surgery of the right hip. The Board further finds that the preponderance of the evidence is against the Veteran’s appeal for an initial compensable disability rating for right hip limitation of flexion. In denying such ratings, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. Neither the Veteran nor his representative have raised any other issues, nor have any other issues been reasonably raised by the record. See, Doucette v. Shulkin, 28 Vet. App. 366, 69-70 (2017). 2. Entitlement to an initial disability rating in excess of 10 percent for femoral acetabular impingement syndrome with osteoarthritis and degenerative arthritis of the left hip with residuals status post arthroscopic surgery of the left hip and to an initial compensable disability rating for left hip limitation of flexion, both prior to January 15, 2018. The Veteran contends that he is entitled to an initial disability rating in excess of 10 percent for femoral acetabular impingement syndrome with osteoarthritis and degenerative arthritis of the left hip with residuals status post arthroscopic surgery of the left hip and an initial compensable disability rating for left hip limitation of flexion, both prior to January 15, 2018. Service connection for femoral acetabular impingement syndrome with osteoarthritis and degenerative arthritis of the left hip with residuals status post arthroscopic surgery of the left hip was granted in a November 2015 rating decision at 10 percent from July 1, 2015, and is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5253, for impairment of the thigh. Under Diagnostic Code 5253, a 10 percent rating is warranted for limitation of rotation of affected leg, cannot toe out more than 15 degrees. A 10 percent rating is also warranted for limitation of adduction, cannot cross legs. A maximum 20 percent rating is warranted for limitation of abduction, motion lost beyond 10 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5253. Service connection for left hip limitation of flexion was granted in a November 2015 rating decision as noncompensable from July 1, 2015, and is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5252, for limitation of flexion of the thigh. Under Diagnostic Code 5252, a 10 percent rating is warranted for flexion limited to 45 degrees. A 20 percent rating is warranted for flexion limited to 30 degrees. A 30 percent rating is warranted for flexion limited to 20 degrees. A maximum 40 percent rating is warranted for flexion limited to 10 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5252. The Veteran underwent a total left hip arthroplasty on January 15, 2018. As such, the Veteran's service-connected left hip disability was rated under Diagnostic Code 5054 as of that date. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See, DeLuca; see also, Mitchell. Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See, Thompson. Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See, Burton. In Correia, the Court held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing “for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint.” In Sharp, the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. The Veteran was afforded a VA hip and thigh conditions examination in June 2015. The Veteran reported chronic bilateral hip pain and a history of bilateral arthroscopic hip surgery in 2012. The Veteran further reported current pain, an inability to run or swim, limitations with walking, the use of stairs and prolonged standing or sitting. He also reported the pain interferes with his sleep. He then reported flare-ups of bilateral hip pain that are associated with limited range of motion and limited mobility. Upon examination, initial ROM of the left hip was measured as follows: 100 degrees flexion with pain; 30 degrees extension; 45 degrees abduction; 25 degrees adduction; 40 degrees external rotation with pain; and 40 degrees internal rotation with pain. The pain, but not the ROM, was noted as causing a functional loss. Pain on weight bearing and localized tenderness or pain on palpation were not noted, but crepitus was. No additional loss of function or range of motion were noted after repetitive use. Regarding repetitive use over time and flare-ups, the examiner stated that he would have to speculate and, as such, could not provide an opinion. Strength testing was normal and ankylosis was not noted. Occasional use of a cane was noted. An October 30, 2015 private treatment record from Orthopaedic Associates of West Florida notes the Veteran presented with bilateral hip pain that had its onset in 2010. The pain was described as mild but throbbing, constant and worsening. It was noted that the Veteran was active and wants to remain that way. His left hip was noted as being worse than his right, but both were described as having "significant symptoms". It was noted that the Veteran walks with a painful, stiff gait and that he "also has a Trendelenberg gait with a slight abductor lurch." X-rays were noted as revealing right hip unilateral primary osteoarthritis and right thigh osteoarthritis. Severe degenerative joint disease was noted. The Veteran was then described as "a candidate for left total hip arthroplasty", noting that both hips were symptomatic and have significant radiographic arthritis. A May 3, 2016 private treatment record from Naval Special Warfare Command notes the Veteran wakes 3 to 4 times nightly and gets up to walk and find a position of comfort due to his hips. It was then noted that his hip pain has caused him to fall when getting out of bed, and has pain that radiates from his hips to his glutes and posterior thighs to the back of his knees. Active range of motion was measured as follows: 110 degrees flexion; 20 degrees extension with pain at end ranges; 20 degrees seated external rotation; 20 degrees internal rotation with pain; 20 degrees abduction; and 10 degrees adduction. Passive range of motion was measured as follows: 120 degrees flexion with pain; 20 degrees extension; 30 degrees supine external and internal rotation; and 20 degrees abduction and adduction. Manual muscle testing was noted as 4 of 5 with pain. Fifty percent squat with increased pain was noted. Bilateral "hip replacement procedures in the coming months" were noted. In his October 2017 appeal to the Board, the Veteran stated that "both of [his] hips are unable to bear any body weight without extreme pain" and that he cannot walk without having extreme pain in both of his hips. He further stated that he "cannot sleep for more than a few hours without waking up from extreme pain" and that the measurements in the rating decision "are based off [his] pain threshold and the flexion and extension limits are all how far [he] can go until it is unbearable." He asserted that he can cross his legs only with "extreme pain" and that he cannot hold the position for long. An October 24, 2017 private treatment record from Orthopaedic Associates of West Florida notes the Veteran reported intermittent hip pain, left greater than the right, and that he has an unstable feeling in the left hip. He the reported that he is unable to run without hip pain. Restricted ROM was noted. A January 8, 2018 private treatment record from Orthopaedic Associates of West Florida notes the Veteran had severe bilateral hip osteoarthritis with intermittent pain, with his left hip being worse than his right. It was further noted that an x-ray revealed "[b]one-on-bone" osteoarthritis in his left hip. The Board finds that the preponderance of the evidence is against a rating in excess of 10 percent for femoral acetabular impingement syndrome with osteoarthritis and degenerative arthritis of the left hip with residuals status post arthroscopic surgery of the left hip prior to January 15, 2018. The Board acknowledges the Veteran’s lay reports of symptoms and that there was functional loss due to pain. However, even considering the Veteran’s lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the Veteran’s statements would not result in symptoms more nearly approximating flexion limited to 30 degrees. Furthermore, the Board finds that the preponderance of the evidence is against an initial compensable rating for left hip limitation of flexion prior to January 15, 2018. The Board acknowledges the Veteran’s lay reports of symptoms and that there was functional loss due to pain. However, even considering the Veteran’s lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the Veteran’s statements that would not result in symptoms more nearly approximating flexion limited to 30 degrees. The Board has also considered the other Diagnostic Codes pertaining to the hip and thigh. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See, Esteban; see also, Lyles. However, aside from the already separate ratings under 5003-5252 and 5003-5353, the rule against pyramiding prohibits any additional ratings under DC 5250, DC 5251, DC 5254, and DC 5255 prior to January 15, 2018. See 38 C.F.R. § 4.14. As such, no additional ratings may be granted. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran’s appeal for a rating in excess of 10 percent for femoral acetabular impingement syndrome with osteoarthritis and degenerative arthritis of the left hip with residuals status post arthroscopic surgery of the left hip prior to January 15, 2018. The Board further finds that the preponderance of the evidence is against the Veteran’s appeal for an initial compensable disability rating for left hip limitation of flexion prior to January 15, 2018. In denying such ratings, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. Neither the Veteran nor his representative have raised any other issues, nor have any other issues been reasonably raised by the record. See, Doucette. 3. Entitlement to a disability rating in excess of 30 percent from March 1, 2019 forward, for left hip total arthroplasty. As discussed above, the Veteran underwent total left hip arthroplasty on January 15, 2018. In a March 2020 rating decision, the Veteran’s left hip disability, previously rated under DC 5003-5252 and DC 5003-5253, was changed to DC 5054 and a temporary evaluation of 100 percent, effective from January 15, 2018 to February 28, 2019, for left hip replacement under 38 C.F.R. § 4.71a, Diagnostic Code 5054 was granted. Thus, the appeal period for the Veteran's initial increased rating for his left hip total arthroplasty is from March 1, 2019 forward. Under DC 5054, the minimum rating is 30 percent, whereas a 50 percent rating is warranted if the affected hip demonstrates moderately severe residual weakness, pain, or limitation of motion following implantation of the prosthesis. A 70 percent disability rating is warranted if the affected hip demonstrates markedly severe residual weakness, pain, or limitation of motion following implantation of the prosthesis. A 90 percent disability rating is warranted if the affected hip demonstrates, following implantation of a prosthesis, painful motion or weakness, such as to require the use of crutches. 38 C.F.R. § 4.71a, Diagnostic Code 5054. The Rating Schedule has not provided definitions for words such as "moderately severe," or "markedly severe." Rather than applying a mechanical formula, the Board must instead evaluate all the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. According to MERRIAM WEBSTER'S COLLEGIATE DICTIONARY 999 (11th Ed. 2007), "moderate" means limited in scope or effect. "Severe" means very painful or harmful or of a great degree. A March 20, 2018 private treatment record from Orthopaedic Associates of West Florida notes the Veteran underwent a left anterior hip replacement on January 15, 2018. the Veteran reported having no pain and that he was "back in the gym increasing his activities" and that his strength was improving. It was further noted that the he "ambulates with a fairly good gait" and that his ROM of the hip was pain-free. A March 26, 2019 private x-ray report from Dr. A. J. Cooper notes that radiographs of the left hip "demonstrate excellent alignment of components with no signs of loosening or other abnormalities." Left hip replacement with collar stem was also noted. The Veteran was afforded a VA hip and thigh conditions examination in December 2019. Diagnoses of bilateral hip osteoarthritis, left hip joint replacement and bilateral acetabular impingement syndrome (includes labral tears), were noted. It was noted that the Veteran underwent left hip replacement on January 15, 2018. The Veteran reported having no pain in his left hip since recovering from surgery. No flare-ups were noted, but he did report that he can sit for 30 minutes before his hip hurts, more right than the left (groin area). He further reported that he can stand for 45 minutes then has to shift around and sit. He then reported that he can walk 100 yards before his right hip pain starts to increase and he has to sit. He then stated that he can walk up or down a flight of stairs but does not do more than that as he has to take one step at a time. Upon examination, initial ROM of the left hip was measured as follows: 110 degrees flexion; 30 degrees extension; 45 degrees abduction; 25 degrees adduction; 60 degrees external rotation; and 40 degrees internal rotation. It was noted that adduction is limited such that the Veteran cannot cross his legs, but that his ROM does not contribute to a functional loss. Pain upon all measurements but external rotation was noted as causing a functional loss. Pain on weight bearing and crepitus were not noted. No additional loss of function or ROM was noted after repetitive use testing. No use of assistive devices was noted. It was noted that pain on passive ROM could not be performed. The Board finds that the preponderance of the evidence shows that the Veteran’s status post left hip total arthroplasty was not manifested by moderately severe residual weakness, pain, or limitation of motion, markedly severe residual weakness, pain, or limitation of motion, or painful motion or weakness, such as to require the use of crutches. The record demonstrates that after his left hip arthroplasty the Veteran was “back in the gym”, improving his strength, walked with a reasonably good gait and was mostly pain free. In light of the above, the Board finds that the preponderance of the evidence is against the Veteran’s appeal for a rating in excess of 30 percent for left hip total arthroplasty from January 15, 2018. In denying such rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. Neither the Veteran nor his representative have raised any other issues, nor have any other issues been reasonably raised by the record. See, Doucette. C. TRUEBA Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Brian P. Keeley The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.